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therapy healthcare Counselling and Psychotherapy Journal
January 2014
OLDER
PEOPLE
AND
TRANSITIONS
Mike Fox explores one of the
most distinguishing features
of therapeutic work with
older adults – the layering
of self as we grow older
I
n the Shared Experience theatre company’s
inspirational 1995 staging of George Eliot’s Mill
on the Floss, Maggie Tulliver, the novel’s main
protagonist, was played by three actresses. They
represented Maggie successively as a free spirited and
passionate child, an adolescent stifled by religious
conviction, and as a young woman, once again selfconfident and able to be assertive. The co-directors of
the production depicted these formative life phases, and
the significant transitions they represented, by keeping
each actress on stage. Therefore, behind the more
self-aware responses of Maggie’s burgeoning maturity,
the audience could see the impetuous and heartfelt
reactions of the child and the conflicted inhibition of the
adolescent, each a simultaneous influence beneath her
‘visible’ current persona.
This captivating visual metaphor portrays the self as
both a continuum and a multifaceted entity, whose
responses in the present moment derive substantially
from the layered effect of previous life stages, with all the
potential for conflict, but also for growth and integration,
that can imply. It illustrates graphically how the person
one has become continues to bear the imprint of previous
change, and of how it was negotiated.
As we grow older this layering inevitably becomes more
complex and subtle, as many developmental theorists,
perhaps most notably Erikson1, have suggested. The
number of transitions encountered increases, each
containing new aspects of experience, and each with the
potential to evoke or be influenced by earlier pivotal times.
I believe that the incremental nature of this layering effect
is one of the most important distinguishing features of
therapeutic work with older adults.
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Recent research, presented at a conference of the British
Psychological Society, has pointed to the phenomenon of
a ‘later life crisis’2, occurring between the ages of 60 and
69. The research suggests it is most commonly triggered
by bereavement or illness, and is characterised by a
reappraisal of previous values and aspirations.
These findings are very welcome, particularly in the
context of an increasing cultural reluctance to
acknowledge and value the later stages of life3. They are,
however, unlikely to surprise anyone who has offered
therapeutic support to people in their 60s, especially
as the additional transition represented by retirement,
often momentous in view of its impact on identity and
structure of daily living, also most commonly falls in
this decade.
At the time the research emerged there was some
debate as to whether, in view of our greater expectation
of longevity, the later life crisis might more realistically
be viewed as the midlife crisis recontextualised within
an increased lifespan. My own experience, as a
counsellor who has specialised in working with older
people, suggests that transitional critical periods in
later life, as they most typically manifest, are not a
deferred response to circumstances that might
previously have been encountered at an earlier life
stage, but rather a distinct phenomenon that has
always existed. Nevertheless, the way in which they
are experienced and processed is likely to be heavily
influenced by earlier significant transitions.
Ageing and the self
The effects of ageing take many of us by surprise. I have
lost count of the number of times I have been told by
clients facing illness, infirmity or memory loss, ‘I never
thought this would happen to me’. We fail to imagine
the realities of ageing and so remain emotionally and
psychologically unprepared for them. It is unsurprising
then that so many older clients who enter counselling
describe an internal sense of a younger self, whose
perspective is in conflict with the restrictions the
process of ageing can bring. This theme, with the
spectrum of emotions that can accompany it, and the
re-evaluation it inevitably demands, represents a rich
and valuable area to explore within therapy. It naturally
conjures retrospection, an impetus to assimilate the
changes that accompany ageing, and the possibility
of imagining and shaping the future on the basis of a
more realistic appraisal of one’s current circumstances.
Within this process lies the potential for recognition
and assimilation of the ‘versions’ of oneself who
inhabited earlier life phases, and consequently greater
personal integration.
Jung wrote, when reviewing his life: ‘There is no linear
evolution; there is only circumambulation of the self’4.
I feel that later life transitions might usefully be viewed
in this way: as the self revisited in the light of new
experience. Rather than the solipsism this might
January 2014
suggest, Jung was describing the ongoing possibility of
conceptualising one’s life within the broader frame that
additional lived experience can allow. Hence our sense
of self may be augmented, rather than diminished, by
later transitional experiences: perhaps paradoxically
in view of the increasing limitation that characterises
physical aspects of ageing.
Jung’s hypothesis has an evident cyclical implication.
Although the term ‘later life crisis’ suggests a single,
perhaps prolonged event, clearly critical periods of
difficulty and re-evaluation in later life are not confined
to a single decade, but are more likely to coincide with
specific and possibly repetitious circumstances such as
bereavement and physical and psychological illness.
For this reason, the older age psychiatrist Dr Marc
Agronin5 makes a distinction between age-associated
issues and the chronological age at which they are
encountered, which may vary according to
circumstance. He also emphasises that adaptation
to ageing is a highly individual process, that we each
have an ‘adaptive style’, and that this aspect of our
personality can change profoundly, as the theatrical
metaphor at the beginning of this article suggests.
Attitude can undoubtedly be crucial. A major
longitudinal study of adult development conducted at
Harvard University revealed a number of components
that are likely to predict successful adaptation to
ageing. Among these is the suggestion that subjective
attitudes to health are better predictors of wellbeing
in old age than health viewed objectively in medical
terms6. Certainly, worry about health can be debilitating
and inhibiting and so can mitigate against participation
in meaningful activity, or the sort of future planning
that fosters self-confidence and hope. Older people who
have begun to experience ill health are often called
upon to tread a path between the extremes of excessive
concern and self-neglect, and I have noticed that those
who are able to adopt a robust and pragmatic attitude
tend to fare better.
It is therefore very important to allow for significant
individual variation when offering psychological
support to an older client group, who are sadly often
categorised as homogeneous by non-specialist services,
and indeed some parts of the media. Factors such as
physical age, personal history, current circumstances,
and attitude to ageing and the issues that accompany
it, will all influence how a transition is negotiated. This
is not to suggest that themes cannot be drawn from
kindred experiences that may typify later stages of life,
rather that they should never obscure the unique
perspective of individual clients.
In saying this, I feel it is nevertheless salutary to
acknowledge how hard it is to envisage the realities of
extreme old age, described by Diana Athill, in a stark
comment as a time in which ‘the body gives no more
pleasure’7, and which to some extent are universal.
The many conversations I have held with older people
therapy
therefore be described as one’s way of being in the
world in response to change. As a broad instance, some
personalities find it easier to relinquish, others feel
the need to fight ageing.
Later life
transitions might
usefully be viewed as
the self revisited in
the light of new
experience
Sometimes a stance towards life, acquired when young,
can remain relatively constant. An example that comes
to mind is of an elderly Jewish client, whom I met
shortly after she had been diagnosed with a dementia
that would increasingly deprive her of the ability to
read and write. Despite a pragmatic awareness of the
consequences of her condition, she spoke movingly of
her profound gratitude at having been able to complete
an important literary project ‘in time’, also for the
constant love and support of her family. On learning
more about her life, I came to feel that this remarkable
reaction to adversity had its roots in a lifelong sense of
good fortune which derived from the prescience her
parents had shown in getting her onto the
Kindertransport, and therefore escaping the atrocities
of the Holocaust.
Role models and re-evaluation
suggest most of us are ill equipped to imagine the
experiential world of the very elderly until we reach
that stage ourselves, a challenge therapists who work
with this client group, but who are mostly younger,
frequently come to recognise. Clearly, there is also a
qualitative difference between adaptations in attitude
and lifestyle a relatively healthy person facing
retirement might be called upon to make and those
that more typically confront people who are living,
increasingly commonly, into their 80s or 90s. The latter
are far more likely to involve the challenge of adjusting
to the inevitability of recurrent loss. In addition,
restrictive health conditions and reduced mobility,
growing likelihoods towards the end of life, are factors
which can markedly diminish the possibility of
responding to one’s circumstances proactively. Hence
the ease with which one might previously have altered
one’s environment, engaged in new pursuits, or been
able to form new relationships, are all likely to decrease.
Seemingly generic statements such as ‘I’ve always been
an active person’ can reveal a deep sense of loss, also
a new uncertainty regarding the future. Similarly,
where disability occurs in old age it allows little time
to learn the coping skills that might be available to a
younger person.
Nevertheless, individuals may respond to these
archetypal challenges very differently. Existential
psychotherapy speaks of a ‘way of being in the world’8.
In part, I understand this to mean a manner of
inhabiting one’s circumstances that is intrinsic to each
individual. The concept of an adaptive style might
I have also been struck by the extent to which earlier
role models can continue to influence the way we
negotiate transitions in later life, with the attitudes
or behaviours that were once displayed by a parent
or other significant forebear particularly likely to
re-emerge in response to current challenge. Of course,
older clients in transition may also re-evaluate early
formative influences, sometimes rejecting, but more
often modifying, an inherited belief or approach.
As an example of this, a practising artist in her 70s, who
sought help because her drinking was out of control,
during our work together became able to reflect on the
way in which her relationship with alcohol developed,
and in so doing identified two particular sources. The
first stemmed from her mother who was a suffragette
but who, in accordance with the time in which she lived,
had been forced to give up her teaching post when she
married. In consequence, as an art student, my client
would drink pints of beer, which was then very unusual
for women, to demonstrate parity with her fellow
students who were mainly male. She saw this as a way
of expressing her sense of emancipation as a woman,
and also of defining herself as someone more able to
exercise independence than had been possible for her
parents’ generation.
The second influence came from her tutors, some
of whom were highly cultured with considerable
reputations in the art world. From them, she learned a
love of fine wines and international cuisine, and she
came to realise that her aesthetic appreciation of wine
derived strongly from these associations with glamour
and the broadening of her early horizons. Therefore, her
initial relationship with alcohol was characterised by a
sense of expansiveness and increased possibility, also
an element of rebellion. Because alcohol had become
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associated with the development of her identity as an
artist and a woman moving more freely in a world where
previously men had dominated, it had evolved into a
metaphor for liberation and autonomy. This insight
allowed her to appreciate that, paradoxically, her
current relationship with alcohol represented a source
of restriction, through its destructive effect on her
health and confidence. Seeing this clearly informed her
resolve to become abstinent, which she achieved, while
still honouring the former role of alcohol in her life by
continuing to serve wine to guests when she hosted
dinner parties9.
Considering age and era as
cultural factors
As these brief examples illustrate, early factors within
an older person’s cultural background can continue to
have a profound bearing upon the way they negotiate
transitions, a prominent component being the era in
which they grew up, and its surrounding mores. To
broaden this point, the stoicism I frequently encounter
in my oldest clients, by its very prevalence, clearly
derives from an earlier collective response to adversity.
Toughing it out or making do, characteristics that were
particularly encouraged during wartime or periods of
austerity, may re-emerge as a personal philosophy in
times of current individual difficulty.
January 2014
I have sometimes heard counsellors who are unused
to working with older clients lament this phenomenon,
viewing it as an unwillingness or inability to express
feelings such as rage, despondency and frustration, and
thereby find relief or catharsis. However, in addition to
representing a personal resource that can serve well in
the face of hardships that accompany old age, stoicism
might also be seen as a style of communication that
says much about the way an individual’s background
continues to inform their response to change. Therefore,
I feel it is helpful to view the stoic client’s way of sharing
information, and particularly of disclosing intimate
material, as a probable aspect of the culture of reticence
and forbearance in which it was often formed.
This type of client may convey much while saying little.
I remember once facilitating an older men’s group in
which the members complemented the robust health
and upright posture of a former guardsman, who later
quietly sought me out to acknowledge in a single
sentence how well his wife, now deceased, had looked
after him. I find it difficult to describe the wealth of
feeling and meaning conveyed by these few words.
On another equally nuanced occasion, a 96-year-old
former engineer, recently bereaved after a marriage of
74 years, recalled in seemingly objective language how
the loss of his wife reminded him of their first separation
during wartime.
While the simplicity of his account nevertheless
conveyed a palpable sense of grief, he was also reminded
of a time when he felt potent, skilled and able to adapt
rapidly to the dramatically changing circumstances
he had encountered. As our work together
continued, similar memories seemed to
connect him to a renewed appreciation of
these resources within his personality
and, a lifelong practical man, with
help from family members he
began to undertake small
decorating tasks within
his home.
Early factors
within an older person’s
cultural background
can continue to have a
profound bearing upon
the way they negotiate
transitions
This example
notwithstanding, many
events in later life can
create an erosion of
identity, a frequent
component of crisis
in older people, and
perhaps nowhere is
the layering effect of
previous transitions
more evident than in
bereavement. When
we are bereaved, we
lose a person but also
our role in relation to
that person. When we
have fewer roles that
therapy
connect us to others, our sense of self is more easily
diminished, and our sense of relatedness more
difficult to sustain. Hence, the psychological effects
of bereavement can be incremental, especially as,
in later life, the experience of bereavement may be
contextualised within a broader frame of loss.
For many people, retirement also can represent the
loss of some integral aspects of identity, particularly
for those whose working role has been central to their
lives. Work typically offers structure and routine, which
some retirees find difficult to replicate in the absence
of any external imperative. Having listened to many
descriptions of my older clients’ daily activities,
I believe it is difficult to overestimate how much
reassurance we draw, and sense of self we derive, from
the simple habits of daily life; also how disconcerting
it can be when these are changed abruptly. Crucially,
however, unlike bereavement, retirement is an
experience that can usually be planned for, although its
consequences may nevertheless be hard to anticipate.
In recent times, organisations such as Age UK have
encouraged us to approach retirement as a process,
rather than the fixed event it was once considered to
be10. The discussions I have had with clients who are
considering the issue of retirement suggest that, in
psychological terms, this ideally involves a gradual
and conscious disassociation from our working role
and the habits that accompany it, while simultaneously
new possibilities are considered and put in place.
Narrative and integrating
the past
‘...the person’s concept of self can best be understood
as comprising a self-narrative that tells the story of
the whole of a life,’ writes Polkinghorne11. ‘This selfnarrative gives coherence to the multiplicity of
episodes, events and relationships experienced in
the course of a life to date, including the prospective
anticipation of its ending.’
I hope the brief extracts of client work I have included
above demonstrate how the act of describing and
reflecting upon salient events within an extensive
personal history can enrich and clarify an older person’s
sense of who they are and how they became that way.
The past, viewed at random, can easily seem like a
collection of disparate episodes, particularly when age
distances us from early memories. Retrospection, and
the stories that accompany it, are a natural resource for
therapists working with older clients, and the stories
older people tell offer testimony to the unifying
tendency inherent in therapeutic narrative. The ability
to view one’s current lifespan more holistically, to
develop an appreciation of cause and effect, to clarify
and describe belief systems and to recognise and
integrate value from previous experience, are all
possibilities for older people in transition who seek
help from therapy.
My former colleague, the psychiatrist Dr Martin
Blanchard, has written passionately about the nihilistic
attitudes to old age that so often prevail in modern
culture9. Nihilism is one of the ways we defend against
disappointment. It could perhaps be viewed as a fear of
hoping, and hope, sadly, is often portrayed as an
exclusive province of the young. However, as a
character in a story by Penelope Fitzgerald suggests:
‘Growing old is… a crime of which we grow more guilty
every day’12. If we are able to acknowledge this selfevident truth, the process of ageing, in which we are
each involved, can lend us empathy with those who are
like us but have progressed further.
Mike Fox currently works as a specialist haematology
counsellor at University College London Hospital. With
Lesley Wilson, he is co-author of Counselling Older
People with Alcohol Problems (Jessica Kingsley
Publishers; 2011).
REFERENCES
1
Erikson EH. Childhood and Society. London: Vintage; 1995.
2
ttp://www.bps.org.uk/news/annual-conference-paper-looks-later-lifeh
crisis
3
ttp://www.jrf.org.uk/sites/files/jrf/older-people-and-high-support-needsh
full.pdf
4
Jung CG. Memories, dreams, reflections. London: Fontana; 1972.
5
gronin ME. Therapy with older clients. New York: WW Norton & Company
A
Inc; 2010.
6
Valliant GE. Ageing well. Boston: Little, Brown; 2002.
7
omment heard on a radio programme (unsourced). For more information,
C
see www.spectator.co.uk/books/427721/growing-old-gracefully-2/
8
ttp://poeticsofaging.org/wordpress/wp-content/uploads/2011/11/
h
Bugental-and-Yalom-article.pdf
9
ox M, Wilson L. Counselling older people with alcohol problems. London:
F
Jessica Kingsley Publishers; 2011.
10
dams GA, Beehr TA (eds). Retirement: reasons, processes, and results.
A
New York: Springer Publishing Company; 2003.
11
olkinghorne DE. Cited in McLeod J (ed). Narrative and psychotherapy.
P
London: Sage Publications Ltd; 1997.
12
Fitzgerald P. The means of escape. London: Flamingo; 2001,
Reader response
The author welcomes feedback about this
article. To contact Mike, please email
[email protected]. To contact the
journal, email [email protected]
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